A study by Dr. David Holtgrave, an expert on HIV prevention at the Johns Hopkins Bloomberg School of Public Health-Baltimore, says a program targeting people at high risk for HIV that offers counseling would be more effective than routine testing of those ages 13 to 64 regardless of risk, as recommended by CDC. The CDC plan does not require counseling and allows patients to refuse to be tested.
The study said implementing CDC's plan would cost $864 million a year. Holtgrave maintains that for the same price, a plan targeting those at high risk that offers counseling could detect more than three times as many HIV-positive people and prevent four times as many new infections. Holtgrave's analysis found that CDC's testing strategy could diagnose about 57,000 HIV cases in a one-year period. However, a strategy that focuses on likely HIV patients - by geography, health care setting or risk behavior - would identify 188,000 people with HIV out of the estimated 250,000-300,000 people in the United States who have HIV but do not know it, according to Holtgrave.
Holtgrave said the targeted approach would focus testing mainly on clinics and emergency departments that treat the uninsured, on areas with a higher-than-normal percentage of HIV infection, or on physicians' assessments of risky behavior. It would use counseling as a means of preventing the spread of HIV.
CDC's 1993 guidelines called for routine testing of high-risk patients and of patients in settings with an HIV prevalence of greater than 1 percent. Its updated regulations, announced in September, are designed to simplify the testing process and remove barriers to screening toward the goals of making HIV testing a part of routine care and of diagnosing more HIV-infected pregnant women.
"Our point of view is this is not a question of either-or," said Dr. Bernard Branson of CDC's division of HIV/AIDS prevention. "You really do need both approaches. You need targeted risk-based testing, and you need broader screening. Risk-based screening misses about half of HIV-infected people in the health care setting."
"Providers are often unwilling to do risk assessments, and patients are often unwilling to be labeled as at high risk for HIV," Branson said in a telephone interview. "Those features have told us that risk-based screening will be insufficient to find all of the people that will be HIV-infected."
The full study, "Costs and Consequences of the US Centers for Disease Control and Prevention's Recommendations for Opt-Out HIV Testing," appears in the online journal Public Library of Science: Medicine (2007;4(6);e194 doi:10.1371/journal.pmed.0040194).
Reuters (06.11.07):: Julie Steenhuysen
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